Surgical Management Surgical Management of of HiatalHiatal HerniasHernias

Manuel A. Molina, M.D.Manuel A. Molina, M.D.University Hospital at BrooklynUniversity Hospital at Brooklyn

SUNY Downstate Medical CenterSUNY Downstate Medical Center

HiatalHiatal HerniasHernias

nn Described for the first time by Henry Described for the first time by Henry IngersollIngersollBowditchBowditch in 1853.in 1853.

nn AkeAke AkerlundAkerlund first to use term first to use term ““paraesophagealparaesophagealherniahernia”” in 1926 for acquired in 1926 for acquired hiatalhiatal hernia.hernia.

nn ParaesophagealParaesophageal hernias 3 hernias 3 –– 15% of all 15% of all hiatalhiatalhernias. 90,000 patients in 1997.hernias. 90,000 patients in 1997.

nn Incidence in general population range between Incidence in general population range between 15 and 45 per 100,000. 15 and 45 per 100,000.

nn Associated with increase age.Associated with increase age.

DiagnosisDiagnosisnn Symptoms: Acid reflux symptoms 46% (5Symptoms: Acid reflux symptoms 46% (5--85%) 85%)

of patients with of patients with paraesophagealparaesophageal hernias. Anemia hernias. Anemia in 20in 20--30%.30%.

nn Post Post prandialprandial chest pain, vomiting or dry heaves chest pain, vomiting or dry heaves in partial or complete gastric outlet obstruction.in partial or complete gastric outlet obstruction.

nn Acute symptoms associated with severe Acute symptoms associated with severe complications such as strangulation, perforation complications such as strangulation, perforation and bleeding.and bleeding.

nn 24h pH probe: abnormal acid reflux in 70% of 24h pH probe: abnormal acid reflux in 70% of patients with type II patients with type II hiatalhiatal hernias. Important hernias. Important when planning a 360when planning a 360°° wrap.wrap.

nn Physical exam: decreased breath sounds, Physical exam: decreased breath sounds, dullness on percussion or audible bowel sounds dullness on percussion or audible bowel sounds over the left over the left hemithoraxhemithorax..

nn Chest XR: airChest XR: air--fluid level behind cardiac fluid level behind cardiac silhouette.silhouette.

nn UGIS: diagnostic in virtually every patient and UGIS: diagnostic in virtually every patient and provides information regarding the type.provides information regarding the type.

nn EndoscopyEndoscopy essential to rule out esophageal or essential to rule out esophageal or gastric pathology.gastric pathology.

CXRCXR

ClassificationClassification

nn 1. Type I: The GE junction 1. Type I: The GE junction displaced superior to hiatus. displaced superior to hiatus.

nn 2. Type II: GE junction 2. Type II: GE junction normal position. normal position. FundusFundus/whole stomach /whole stomach superior to hiatus.superior to hiatus.

nn 3. Type III: Combination of 3. Type III: Combination of Type I and Type II.Type I and Type II.

nn 4. Type IV: Large 4. Type IV: Large hiatalhiataldefect with colon, spleen, or defect with colon, spleen, or other visceral in the sac. other visceral in the sac.

Type IType I

Type IIType II

PathophysiologyPathophysiology

nn Advanced stage of type I hernias.Advanced stage of type I hernias.nn Characterized by large diaphragmatic opening Characterized by large diaphragmatic opening

and lax and lax gastrosplenicgastrosplenic and and gastrocolicgastrocolic ligaments.ligaments.nn Mobile portions of the stomach migrate into the Mobile portions of the stomach migrate into the

posterior posterior mediastinummediastinum as a result of negative as a result of negative intrathoracicintrathoracic and positive intraand positive intra--abdominal abdominal pressures.pressures.

nn Fixed GE junction to Fixed GE junction to preaorticpreaortic fascia results in fascia results in Type II hernia.Type II hernia.

Lax Lax ligamentusligamentus attachments as hernia enlarges, attachments as hernia enlarges, allows the stomach to rotate. Around its allows the stomach to rotate. Around its longitudinal axis known as longitudinal axis known as organoaxialorganoaxial volvulusvolvulus, , or around its transverse axis known as or around its transverse axis known as mesentericoaxialmesentericoaxial volvulusvolvulus..

Clinical presentationClinical presentationClinical presentationClinical presentation

PATHOPHYSIOLOGY

Asymptomatic

Minor symptoms

Severe symptoms

HeartburnBelching

IndigestionOccasional retching

Other GERD-type symptoms

Incompetent LESIncreased intragastric pressure

DysphagiaNausea/VomitingBloating/retchingPostprandial pain

Inability of belching/vomitingInability to pass NGT

Peritonitis

Progressive migration of stomach into chestProgressive expansion of the stomach

Compression of esophagusIncarceration

VolvulusStrangulation

Belching/Anemia

Ulceration/erosion of gastric mucosa due to:Ischemia

Compression from cruraStasis/congestion of herniated stomach

Dyspnea/PneumoniaCardiac arrhythmias

Pleural effusionMediastinitis

Mechanical compressionAspirationPerforation

TreatmentTreatment

nn Inability to pass a NGT in the presence of acute Inability to pass a NGT in the presence of acute symptoms is an indication for emergency symptoms is an indication for emergency surgical repair.surgical repair.

nn If NGT can be passed and the stomach If NGT can be passed and the stomach decompressed, the patient should be optimized decompressed, the patient should be optimized and perform a and perform a semielectivesemielective procedure.procedure.

nn Operative principles reduction of the hernia, Operative principles reduction of the hernia, excision of the sac and partial closure of the excision of the sac and partial closure of the hiatus.hiatus.

nn In high risk patients anterior In high risk patients anterior gastropexygastropexy via via PEG prevents PEG prevents organoaxialorganoaxial volvulusvolvulus..

nn Approaches: Approaches: transthoracictransthoracic, , transabdominaltransabdominal, , laparoscopic. laparoscopic.

nn 40% re40% re--herniationherniation with laparoscopic approach. with laparoscopic approach. Usually small and asymptomatic.Usually small and asymptomatic.

nn Partial Partial fundoplicationfundoplication: posterior fixation of the : posterior fixation of the stomach, improves acid reflux, avoid distal stomach, improves acid reflux, avoid distal esophagus motility problems when preesophagus motility problems when pre--op op motility studies are not available. motility studies are not available.

nn Anterior Anterior gastropexygastropexy: no additional risk, provides : no additional risk, provides anterior wall fixation.anterior wall fixation.

nn In large hernias a relaxing incision in the In large hernias a relaxing incision in the diaphragm to decrease tension in hiatus. The diaphragm to decrease tension in hiatus. The incision should be closed with PTFE patch.incision should be closed with PTFE patch.

nn HiatalHiatal patch repair, low tension but mesh and patch repair, low tension but mesh and esophagus are in direct contact increasing the esophagus are in direct contact increasing the chance of erosion and infection.chance of erosion and infection.

nn Laparoscopic mesh Laparoscopic mesh cruroplastycruroplasty only 3.7% only 3.7% recurrence. recurrence. (Champion et (Champion et al.,Surgicalal.,Surgical EndoscopyEndoscopy, 2003, 17: 551, 2003, 17: 551--553).553).

nn Important in Important in paraesophagealparaesophageal hernia repair is the hernia repair is the assessment of esophageal length. High assessment of esophageal length. High incidence of recurrent incidence of recurrent herniationherniation if intraif intra--abdominal esophagus <2.5cm after dissection abdominal esophagus <2.5cm after dissection and mobilization of the GE junctionand mobilization of the GE junction

nn Collis Collis gastroplastygastroplasty is advised if shortening of the is advised if shortening of the esophagus is noticed.esophagus is noticed.

Laparoscopic repairLaparoscopic repair

Elective surgery Elective surgery vsvs watchful waitingwatchful waiting((StylopoulosStylopoulos et al, Ann et al, Ann SurgSurg 236: 492236: 492--501, 2002)501, 2002)

nn Asymptomatic patients have 85% annual Asymptomatic patients have 85% annual probability of remaining asymptomatic.probability of remaining asymptomatic.

nn 15% will develop new symptoms requiring 15% will develop new symptoms requiring elective repair.elective repair.

nn 1% of patients with new symptoms will require 1% of patients with new symptoms will require emergent surgery.emergent surgery.

nn Emergency operation 5.4% mortality according Emergency operation 5.4% mortality according to Nationwide Inpatient Sample.to Nationwide Inpatient Sample.

nn Elective laparoscopic hernia repair 1.38% Elective laparoscopic hernia repair 1.38% mortality rate.mortality rate.

Elective Elective vsvs emergency repairemergency repair

0.00%

2.00%

4.00%

6.00%

Mortality

ElectiverepairEmergrepair 0.00%

10.00%20.00%30.00%40.00%

G I G II G III

ElectiveEmerg

Grade I: nonGrade I: non--lifelife--threatening alterations from the ideal post op course, never threatening alterations from the ideal post op course, never hospital stay greater than twice the median. No residual disabilhospital stay greater than twice the median. No residual disability.ity.

Grade II: potentially lifeGrade II: potentially life--threatening complications or complications that result in threatening complications or complications that result in hospital stay greater than twice the median. No residual disabilhospital stay greater than twice the median. No residual disability or organ ity or organ resection.resection.

Grade III: complications with residual disability including orgaGrade III: complications with residual disability including organ resection or n resection or persistent lifepersistent life--threatening condition. Surgery related symptoms.threatening condition. Surgery related symptoms.

((ClavienClavien et al. Surgery 111: 518et al. Surgery 111: 518--526, 1992).526, 1992).

ConclusionsConclusions

nn Surgery is not routinely indicated in asymptomatic Surgery is not routinely indicated in asymptomatic patients unless development of progressive symptoms patients unless development of progressive symptoms or severe acute symptoms.or severe acute symptoms.

nn Patients with bleeding or obstruction symptoms related Patients with bleeding or obstruction symptoms related to to paraesophagealparaesophageal hernias should undergo surgical hernias should undergo surgical repair.repair.

nn Watchful waiting is advised for asymptomatic as well as Watchful waiting is advised for asymptomatic as well as minimally symptomatic patients who are elderly or have minimally symptomatic patients who are elderly or have significant significant comorbidcomorbid conditions.conditions.

nn Laparoscopic repair is a appropriate method.Laparoscopic repair is a appropriate method.

nn Tension free repair is advisable to prevent Tension free repair is advisable to prevent recurrences.recurrences.

nn Anterior Anterior gastropexygastropexy and partial and partial fundoplicationfundoplicationare indicated for fixation of the anterior and are indicated for fixation of the anterior and posterior gastric wall and to prevent posterior gastric wall and to prevent volvulusvolvulus..